CLAIMS BILLING & ADJUDICATION TRAINING 2013-2014

1. CLAIMSBILLING & ADJUDICATIONTRAINING2013-2014 April 22, 2014 Debra A. Schuchert Director of Network Operations & Compliance

2. Synergy’s Procedure Code List with Descriptions / Fee Schedule • Synergy’s Fee Schedule is located on the “G” drive & is identified as FEE SCREEN • The Fee Screen identifies our procedural coding. When new regulations are instituted for coding, a committee meets to discuss all aspects of the code such as clinical description, # of units to be authorized, pricing etc. Upon approval of the procedure code, it is then entered in the Synergy Fee Screen. • The Fee Schedule identifies the following: • Procedure Code Descriptions • Revenue Code (In Patient Hospital Stay) • Procedure Code • Modifier • COB Requirements • Units • Fee Screen/Schedule Rate • Internal Modifier

3. Contracts • The Direct Contracts, Limited Case Agreements, & Residential –Subcontracts through Wayne Center are identified on a List located on the “G” drive under the Claims Department. • Direct Contracts The providers are listed as 1st Tier Subcontracts with DWMHA. Fair Employment Practice (F.E.P.) Certificates are required for these providers, with the exception of Network 180/ Kent County Community Mental Health Authority because this provider is outside of Wayne County jurisdiction. • Limited Case Agreements The provider is servicing one consumer or the services are for a limited time frame. • Residential Homes The provider is servicing the consumer/consumers in a residential home. We may have one or more consumers at each home.

4. Claims Policies & Procedures The following Claim policies and procedures are located on the “G” drive under Claims Department. C-001 New Paper Claims Submission into STARS C-002 Claims Adjudication C-003 Family & Friend Respite Billing& Payment Process (09-30-2008 policy discontinued) C-004 Medicaid Claims Verification Audit Review C-005 Coordination of Benefits C-006 Camp Stay Reimbursement C-007 Claims Override Process C-008 Ability to Pay • Policy # C-004 has been revised as of March 2013. Claims audit review is entered into MH-WIN. Additional attachments: • C-OO4h – Compliance & Breach Notification on Protected Health Information and Personal Record Information • C-OO4i - Compliance Statement

5. Claims Department Meeting Minutes • The Claims Department meeting minutes are identified by fiscal year and located on the “G” drive under the Claims Department.

6. Fair Employment PracticeFEP • Synergy and all Direct Contract Providers are responsible for submitting a Fair Employment Practice (FEP) application to the Authority for approval. The Authority produces the FEP Certificate. All Certificates must be renewed upon expiration date. The certificates can be issued for a one, two or three year period. • Synergy has complied with all the requirements of the Wayne County Business Certification Program & has established Compliance with Wayne County’s Fair Employment Practices Resolution. Therefore, Synergy Partners, LLC has been issued the Wayne County Human Relations Certificate (FEP). • Synergy is responsible for submitting the following to DWMHA (Authority) annually or whenever provider changes occur. (I.e. additions, deletions, address changes etc.) • DWMHA 1st Tier Subcontractor Report • Fair Employment Practice Certificates on all Direct Contract providers

7. DWMHA MCPN Medicaid/Other Individual Claims Verification Audit • The verification audit is due to the Authority on a “quarterly” basis. • 2% of Medicaid consumers & Non-Medicaid consumers are randomly sampled and a report is produced by Bessie T. – Chief of IT & Security • The Claim Adjudicators review the claims and answer the questionnaire that list questions concerning eligibility, services rendered, documentation substantiating the services rendered, appropriate CPT/HCPCS & revenue codes billed, third party fees collected, Ability to Pay determinations made, etc. • Audit is being submitted through MH-WIN

8. Provider Performance Audits • Annual on site audits are conducted on selected providers. The Claims Department coordinates efforts with the Quality Management Department when conducting the on-site audits. • The Claim Adjudicators have a Performance Monitoring Audit Tool that is used for each provider. The documents are reviewed and the specific audit forms are completed. Each provider receives a detailed audit report explaining the findings. • The Claim Adjudicator will also conduct “random” internal audits on providers when issues arise or on selected procedure codes. There are specific reports that are completed for these audits. • The Internal Corporate Compliance Investigation Report • Corporate Compliance Response to a Governmental Inquiry or Investigation

9. Timely Claims Submission • When the provider submits a claim over 60 days from the date of service, an edit will appear on the adjudication screen alerting the provider and Claim Adjudicator that claim is past the 60 day filing limit and a Reconsideration Review Form must be completed by the provider and submitted for approval by the Chief Financial Officer (CFO). If the Reconsideration Review Form is not approved by the CFO, the claim will zero pay.